Page 40 - Read Online

Bertolini et al. Plast Aesthet Res 2023;10:34 https://dx.doi.org/10.20517/2347-9264.2022.121 Page 3 of 25

Table 1. Boyes Preoperative Classification of Tendon Injury
Grade Conditions Description
Grade I Good Minimal scar, mobile joints
Grade II Cicatrix Significant scar damage due to previous surgery or infections
Grade III Joint damage Joint damage, decreased range of motion
Grade IV Nerve damage Digital nerve injury
Grade V Multiple system injury Combination of II, III, IV

A two-stage tendon grafting reconstruction is recommended in conditions with a high risk of graft adhesion
in a compromised tendon sheath and/or an insufficient pulley system. Using a silicone rod in the first
surgical stage will create a new pseudosheath to allow free gliding of the tendon graft.

A vascularized flexor tendon transfer is a highly complex procedure that requires the sacrifice of the ulnar
artery. This technique should only be performed by experienced surgeons in extremely selected cases
involving injuries classified between Boyes’ Grades 3 and 5.

Injuries with a worse prognosis include crush trauma, significant soft tissue loss, joint fractures, or
associated neurovascular damage. Young age is often associated with a better prognosis; however, it is
important to remember that if rehabilitation is too intense, it may compromise a patient's compliance.

An additional therapeutic alternative described in literature is the tendon prosthesis, which can also be used
[10]
as a permanent implant in patients with a poor prognosis .

Regardless of the surgical choice, it is crucial for the patient to be compliant to undertake intensive
rehabilitation therapy to reduce soft tissue contractures and maintain flexible joints before and after
surgery .
[11]
Single-stage reconstruction
This reconstruction involves replacing the missed or damaged tendon segment with a free tendon graft.
Until the 1970s, single-stage reconstruction was commonly performed for acute tendon classes in zone II
because of the high failure rate of direct repair. Today, due to improvements in primary repair, this surgical
approach is almost dismissed [12,13] .

In cases of tendon gaps, different types of tendon grafts can be used. The availability and desired length of
the graft should always be evaluated before harvesting. The palmaris longus is the most commonly used
tendon graft due to its easy accessibility, good quality, and low morbidity at the harvest site. Several clinical
studies have shown its effectiveness in reconstructive use [1,2,4,5,14] . If long palmar is not present in the involved
arm, the plantaris tendon may serve as an alternative. This graft is of considerable length, allowing it to
extend from the digital apex to the forearm. However, it is often insubstantial, and preoperative
ultrasonography can prevent unnecessary donor site mobility. Extensor tendons of II-III-IV toes can also be
utilized, especially if a multi-toe graft is needed. In case of small gaps instead, the proper extensor tendons
of the II and V fingers can also be used [4,15] . It has been observed that intrasynovial grafts, such as FDS and
toe flexors, have better morphological and functional characteristics than extrasynovial grafts, creating fewer
adhesions during tendon healing. However, the intrasynovial component of the toe flexors is generally too
short to bridge the entire tendon gap [2,16,17] .